Provider Demographics
NPI:1467634477
Name:RICHARD M. KOOTMAN M.D.,P.C.
Entity Type:Organization
Organization Name:RICHARD M. KOOTMAN M.D.,P.C.
Other - Org Name:ARROWHEAD EYE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOOTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-561-1995
Mailing Address - Street 1:13943 N. 91ST AVE BLDG G
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3687
Mailing Address - Country:US
Mailing Address - Phone:623-561-1995
Mailing Address - Fax:623-561-2446
Practice Address - Street 1:13943 N. 91ST AVE BLDG G
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3687
Practice Address - Country:US
Practice Address - Phone:623-561-1995
Practice Address - Fax:623-561-2446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19610174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1258130001Medicare NSC
AZZWCLFPMedicare PIN